Sublingual gland
◼️It is the smallest of the three major paired salivary glands.
◼️The gland lies in the floor of the oral cavity immediately lateral to the submandibular duct (Wharton's duct) and associated lingual nerve (see previous post).
◼️The sublingual gland lies directly against the medial surface of the mandible making a shallow groove called sublingual fossa, it is above the anterior 1/3 of mylohyoid muscle. (see above fig).
◼️The superior surface of the gland raises a fold of mucosa at the floor of oral cavity known as the sublingual fold, which is easily visible, the gland is drained by numerous minor sublingual ducts that opens onto the crest of the sublingual fold.
◼️Occasionally the anterior portion of the gland is drained by a major sublingual duct that opens together with Wharton's duct besides the base of the lingual frenulum.
#Salivary
#Surgery
◼️It is the smallest of the three major paired salivary glands.
◼️The gland lies in the floor of the oral cavity immediately lateral to the submandibular duct (Wharton's duct) and associated lingual nerve (see previous post).
◼️The sublingual gland lies directly against the medial surface of the mandible making a shallow groove called sublingual fossa, it is above the anterior 1/3 of mylohyoid muscle. (see above fig).
◼️The superior surface of the gland raises a fold of mucosa at the floor of oral cavity known as the sublingual fold, which is easily visible, the gland is drained by numerous minor sublingual ducts that opens onto the crest of the sublingual fold.
◼️Occasionally the anterior portion of the gland is drained by a major sublingual duct that opens together with Wharton's duct besides the base of the lingual frenulum.
#Salivary
#Surgery
Submandibular gland
◼️It is smaller than the parotid gland, but larger than the sublingual gland.
◼️On each side, the submandibular gland consists of two parts, the superficial part is outside the bounderies of the oral cavity and it lies beneath the mylohyoid muscle (see fig), it has a greater volume than the deep part of the gland.
◼️The deep part loops around the posterior margin of mylohyoid muscle to enter the floor of the oral cavity, it is lateral to the base of the tongue lying on the outer surface of hyoglossus muscle.
◼️The deep part makes an impression on the inner aspect of the mandible, which is known as the submandibular fossa.
◼️The submandibular duct (Wharton's duct) emerge from the medial aspect of the deep part, and passes forwards in the floor to open beside the base of the lingual frenulum.
◼️The lingual nerve (a sensory nerve from the mandibular nerve) passes beneath the submandibular duct crossing it from a lateral to a medial direction (see above fig).
#Salivary
#Surgery
◼️It is smaller than the parotid gland, but larger than the sublingual gland.
◼️On each side, the submandibular gland consists of two parts, the superficial part is outside the bounderies of the oral cavity and it lies beneath the mylohyoid muscle (see fig), it has a greater volume than the deep part of the gland.
◼️The deep part loops around the posterior margin of mylohyoid muscle to enter the floor of the oral cavity, it is lateral to the base of the tongue lying on the outer surface of hyoglossus muscle.
◼️The deep part makes an impression on the inner aspect of the mandible, which is known as the submandibular fossa.
◼️The submandibular duct (Wharton's duct) emerge from the medial aspect of the deep part, and passes forwards in the floor to open beside the base of the lingual frenulum.
◼️The lingual nerve (a sensory nerve from the mandibular nerve) passes beneath the submandibular duct crossing it from a lateral to a medial direction (see above fig).
#Salivary
#Surgery
Note
The parotid gland is innervated by the auriculotemporal nerve, which is a branch of the mandibular division of trigeminal nerve, this branch provide sensory innervation and carries postganglionic parasympathetic nerve fibres to the parotid gland for secretomotor activity, these fibres originate in the otic ganglion associated with the mandibular nerve, the preganglionic nerve fibres comes from the glossopharyngeal nerve.
#Salivary
#Surgery
The parotid gland is innervated by the auriculotemporal nerve, which is a branch of the mandibular division of trigeminal nerve, this branch provide sensory innervation and carries postganglionic parasympathetic nerve fibres to the parotid gland for secretomotor activity, these fibres originate in the otic ganglion associated with the mandibular nerve, the preganglionic nerve fibres comes from the glossopharyngeal nerve.
#Salivary
#Surgery
Relationship of facial nerve to the parotid gland
◼️The facial nerve exists the skull through the stylomastoid foramen, it then directly enters the substance of the parotid gland.
◼️Within the parotid gland, the facial nerve usually divide into an upper and lower nerve trunks, which furthur divide and anastomose within the gland forming the parotid plexus of nerves which is also called Pes Anserinus plexus (see above fig).
◼️The Pes Anserinus divides the parotid glands into two parts, the superficial part (outside the plexus) and the deep part (Deep to Pes Anserinus).
◼️Five branches emerge from Pes Anserinus which include (1) Temporal, (2) Zygomatic, (3) Buccal, (4) Marginal, (5) Cervical, these provide motor innervation to the muscles of the face.
#Salivary
#Surgery
◼️The facial nerve exists the skull through the stylomastoid foramen, it then directly enters the substance of the parotid gland.
◼️Within the parotid gland, the facial nerve usually divide into an upper and lower nerve trunks, which furthur divide and anastomose within the gland forming the parotid plexus of nerves which is also called Pes Anserinus plexus (see above fig).
◼️The Pes Anserinus divides the parotid glands into two parts, the superficial part (outside the plexus) and the deep part (Deep to Pes Anserinus).
◼️Five branches emerge from Pes Anserinus which include (1) Temporal, (2) Zygomatic, (3) Buccal, (4) Marginal, (5) Cervical, these provide motor innervation to the muscles of the face.
#Salivary
#Surgery
Salivary glands
◼️There are about 1000 minor salivary glands which are located in the submucosa and mucosa that lines the tongue, buccal surfaces, and palate of the oral cavity, these glands opens directly via small ducts.
◼️The parotid gland is the largest of the three major pairs of salivary glands, it is located within a shallow triangular trench bordered by (1) sternocleidomastoid muscle behind, (2) Mandibular ramus infront, (3) The base of the triangle made by external auditory meatus and posterior part of zygomatic arch. (see fig)
◼️The parotid duct (Stensen's duct) leaves the anterior aspect of the gland midway between zygomatic arch and corner of the mouth, it traverse the face external to masseter muscle and turns medial to pierce the buccinator muscle and opens adjacent to the upper 2nd molar tooth.
◼️The parotid gland loops around the mandibular ramus, so that it is superficial, posterior and deep to it.
◼️The relationships of parotid gland will be discussed later.
#Salivary
#Surgery
◼️There are about 1000 minor salivary glands which are located in the submucosa and mucosa that lines the tongue, buccal surfaces, and palate of the oral cavity, these glands opens directly via small ducts.
◼️The parotid gland is the largest of the three major pairs of salivary glands, it is located within a shallow triangular trench bordered by (1) sternocleidomastoid muscle behind, (2) Mandibular ramus infront, (3) The base of the triangle made by external auditory meatus and posterior part of zygomatic arch. (see fig)
◼️The parotid duct (Stensen's duct) leaves the anterior aspect of the gland midway between zygomatic arch and corner of the mouth, it traverse the face external to masseter muscle and turns medial to pierce the buccinator muscle and opens adjacent to the upper 2nd molar tooth.
◼️The parotid gland loops around the mandibular ramus, so that it is superficial, posterior and deep to it.
◼️The relationships of parotid gland will be discussed later.
#Salivary
#Surgery
Note: "Serum amylase level and acute pancreatitis"
◼️Serum amylase, an enzyme produced by the exocrine pancreas and released into the circulation in excess amounts with inflammatory conditions of the pancreas, is an important laboratory marker for acute pancreatitis.
◼️In acute pancreatitis serum amylase level is more than 3 times the upper limit of normal value, it is important to understand that the level of amylase does not correlate with the severity of acute pancreatitis, infact, low levels of serum amylase occurs more often in severe cases of acute pancreatitis than in mild cases.
◼️Serum amylase level may be elevated in other conditions, including (1)perforated peptic ulcer, (2)mesenteric infarction, (3) Renal failure, (4) Macro-amylasemia, in such cases serum lipase level or the pancreatic isoenzyme amylase are more specific for the diagnosis.
◼️A normal serum amylase level does not exclude the diagnosis of acute pancreatitis, it is almost immediately elevated with the onset of disease, and remains elevated for 3 to 5 days following the index event, meanwhile its being excreted into the urine, here urinary amylase level may be more beneficial in securing a diagnosis of acute pancreatitis.
#Pancreas
#Surgery
◼️Serum amylase, an enzyme produced by the exocrine pancreas and released into the circulation in excess amounts with inflammatory conditions of the pancreas, is an important laboratory marker for acute pancreatitis.
◼️In acute pancreatitis serum amylase level is more than 3 times the upper limit of normal value, it is important to understand that the level of amylase does not correlate with the severity of acute pancreatitis, infact, low levels of serum amylase occurs more often in severe cases of acute pancreatitis than in mild cases.
◼️Serum amylase level may be elevated in other conditions, including (1)perforated peptic ulcer, (2)mesenteric infarction, (3) Renal failure, (4) Macro-amylasemia, in such cases serum lipase level or the pancreatic isoenzyme amylase are more specific for the diagnosis.
◼️A normal serum amylase level does not exclude the diagnosis of acute pancreatitis, it is almost immediately elevated with the onset of disease, and remains elevated for 3 to 5 days following the index event, meanwhile its being excreted into the urine, here urinary amylase level may be more beneficial in securing a diagnosis of acute pancreatitis.
#Pancreas
#Surgery
Colon vascular supply
◼️The colon is supplied by both the superior and inferior mesenteric arteries which are branches of the aorta.
◼️The superior mesenteric artery (SMA) arise from the anterior surface of the aorta just below the celiac trunk at the level of the lower part of L1.
◼️SMA branches off the ileocolic artery (abscent in 20% of population) which supplies the terminal ileum and proximal ascending colon, it also gives the right colic and middle colic arteries that supply the distal ascending colon and transverse colon respectively.
◼️The inferior mesenteric artery arise from the aorta at about L3 vertebral level, it gives the left colic artery, several sigmoidal branches, and the superior rectal artery which supplies the proximal rectum.
◼️Each of these arteries communicate via anastomoses through the artery of Drummond, this circle of anastomoses is complete in only 15% to 20% of the population.
#Intestinal
#Surgery
◼️The colon is supplied by both the superior and inferior mesenteric arteries which are branches of the aorta.
◼️The superior mesenteric artery (SMA) arise from the anterior surface of the aorta just below the celiac trunk at the level of the lower part of L1.
◼️SMA branches off the ileocolic artery (abscent in 20% of population) which supplies the terminal ileum and proximal ascending colon, it also gives the right colic and middle colic arteries that supply the distal ascending colon and transverse colon respectively.
◼️The inferior mesenteric artery arise from the aorta at about L3 vertebral level, it gives the left colic artery, several sigmoidal branches, and the superior rectal artery which supplies the proximal rectum.
◼️Each of these arteries communicate via anastomoses through the artery of Drummond, this circle of anastomoses is complete in only 15% to 20% of the population.
#Intestinal
#Surgery
Differential diagnosis of a groin lump :
1) Indirect inguinal hernia.
2) Direct inguinal hernia.
3) Femoral hernia.
4) Enlarged cloquet lymph nodes.
5) Saphena varix.
6) Femoral aneurysm.
7) Encysted hydrocele of cord.
8) Hydrocele of canal of Nuck.
9) Hematocele of round ligament.
10) Ectopic testis.
11) Lipoma.
12) Psoas abscess.
13) Enlarged psoas bursa.
14) Ruptured adductor muscles.
#Hernia
#Surgery
1) Indirect inguinal hernia.
2) Direct inguinal hernia.
3) Femoral hernia.
4) Enlarged cloquet lymph nodes.
5) Saphena varix.
6) Femoral aneurysm.
7) Encysted hydrocele of cord.
8) Hydrocele of canal of Nuck.
9) Hematocele of round ligament.
10) Ectopic testis.
11) Lipoma.
12) Psoas abscess.
13) Enlarged psoas bursa.
14) Ruptured adductor muscles.
#Hernia
#Surgery
Strangulation of paraumbilical hernia is frequent which justify operation in nearly all cases, from the image above the fibrous rigid linea alba (black arrow) creates a narrow neck with a rigid edge that makes strangulation likely, in addition sometimes in large hernias loculations due to omental adhesions cause strangulation in a knuckle of intestine in an otherwise soft and non tender hernial sac.
#Hernia
#Surgery
#Hernia
#Surgery
This is a polypropylene mesh used for hernioplasty, this provides structural support to a weak defect, it gained widespread popularity especially with inguinal hernias (Lichtenstein tension-free hernioplasty), it can be used for recurrent paraumbilical hernias or those with very large defect.
#Hernia
#Surgery
#Hernia
#Surgery
Mayo's operation, indicated for small defects on paraumbilical hernias, the operation simply proceed with transverse elliptical incision near the umbilicus, the subcutaneous fat is dissected to reveal the anterior rectus sheath and the neck of the hernia which is incised, the contents are delt with appropriately and then the sac is dissected out and the peritoneum sutured, then the defect is strengthened with overlapping of the aponeuroses on each side of the umbilicus and fixed with sutures the overlap should be 5 to 7.5 cm.
#Hernia
#Surgery
#Hernia
#Surgery
Paraumbilical hernia
◼️It is protrusion of a hernial sac in a weak point at the linea alba above or sometimes below the umbilicus.
◼️It can attain massive size.
◼️It is 5 times more common in females.
◼️Obesity, flabbiness of abdominal muslces and repeated pregnancy are important aetiologic factors.
◼️The neck of this hernia is remarkably narrow when compared to the size of the sac or volume of its contents, thus it is liable for strangulation and require operation.
◼️In longstanding cases the sac may become lobulated due to omental adhesions rendering it irreducible, in addition intertrigo due to friction of adjacent skin surfaces and trophic ulcers are troublesome complications.
◼️Dragging pain due to traction and transient intestinal colic due to partial intestinal obstruction may occur.
#Hernia
#Surgery
◼️It is protrusion of a hernial sac in a weak point at the linea alba above or sometimes below the umbilicus.
◼️It can attain massive size.
◼️It is 5 times more common in females.
◼️Obesity, flabbiness of abdominal muslces and repeated pregnancy are important aetiologic factors.
◼️The neck of this hernia is remarkably narrow when compared to the size of the sac or volume of its contents, thus it is liable for strangulation and require operation.
◼️In longstanding cases the sac may become lobulated due to omental adhesions rendering it irreducible, in addition intertrigo due to friction of adjacent skin surfaces and trophic ulcers are troublesome complications.
◼️Dragging pain due to traction and transient intestinal colic due to partial intestinal obstruction may occur.
#Hernia
#Surgery
Umbilical hernia
◼️It is mostly symptomless.
◼️Strangulation under 3 years of age is rare.
◼️There is no sex predilection, but there is major racial difference because this hernia is 8 times more common in black children than white children.
◼️In 95% of cases in those under 2 years of age, the hernia will spontaneously resolve, because the vast majority of cases resolve on its own, Do nothing but reassurance of the parents.
◼️If it persist at 2 years or more (only in 5%) it will likely not resolve and this herniorrhaphy is indicated.
◼️The operation entails a curved skin incision under the umbilicus with isolated of the sac which is either reduced or transfixed with sutures, the defect in the linea alba is closed.
#Hernia
#Surgery
◼️It is mostly symptomless.
◼️Strangulation under 3 years of age is rare.
◼️There is no sex predilection, but there is major racial difference because this hernia is 8 times more common in black children than white children.
◼️In 95% of cases in those under 2 years of age, the hernia will spontaneously resolve, because the vast majority of cases resolve on its own, Do nothing but reassurance of the parents.
◼️If it persist at 2 years or more (only in 5%) it will likely not resolve and this herniorrhaphy is indicated.
◼️The operation entails a curved skin incision under the umbilicus with isolated of the sac which is either reduced or transfixed with sutures, the defect in the linea alba is closed.
#Hernia
#Surgery